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Please print or type.(Form deoi od forum on aide(12-pdeh)ty nwmter.) Form Approved.OMBNo.2050.0039 <br /> UNIFORM HAZ=DUS 1.GenaraartD Numbef 2Pegetof 3.Emlrgeney Refpenfe Prom d.MMIRMTracktrp Number <br /> WAVE MANIFEST ca OO144419 1 1 1300424-9309 003774561 JJ K <br /> Cmmea Va MUS v <br /> 50 M i-fm99 y GeneratWa Sia Address Of differentthan mauling address) <br /> 179VIA NCOLO l:�lYlY <br /> TRACY,CA 95377 <br /> Generators Phone: 209-83(.4S00 <br /> 6.Tmrapprter 1 Camp Name U.S.EPA ID Numter <br /> EVERGREEN NRONMENTAL SERVICES CADSIS2413282 <br /> 7,Transporter 2 Compimy Nance U.S.EPA ID Number <br /> �gF�IRL�Pb61Le§�slte Addnss u.s.EPA ID Nan�ber <br /> 8880 SMTH AVE. CAD880887418 <br /> NEWARK,CA 94589 <br /> 510-795-4400 <br /> Facto, a Phare: <br /> 90-, 06.U.S.DOT DeEdpli m(newding ProptrShipping Name,Hazard Class,ID Number, 10.Containers 11.Tool 12,Ung 13.Waste Codes <br /> HM and PWking OmuP(If any)) Ne- Type Quantity WE'vc1. <br /> a Z <br /> W <br /> 3. <br /> 4. <br /> td.Sp��i�l Handkng lme uctians andAd&onal lnfa matin ' <br /> P erg <br /> 15. GENERATOR'SIOFFEEEROR'SCERTIFICATION: I herabydeclanelhatthe cements ofthlfeonsignmentare lulyand accuretelydescrtbed at=by the propershIpping eame,ard are dassltied,pacloged, <br /> marked and botedlplagrded,and 11R In all M$Pecff In proper condition for transport according tp applicable ince ationelmid nallonal governmental regulations-ifaxpmt shipmemand I am the Primary <br /> Exporter,I ceNfythetthe cantenla of this consignment conform to the lama of the attached EPAAckmwl aisment of Conserv <br /> 1 gently that the waste minlmbodton stelement tivI led In 40 CFR 26227(e)Of I ism a IsMa quantity garmalor)or(b)(f I am a smal quantity ganerator)is We. <br /> GaneretorefOgamfs P�yraMyped Name g tun <br /> momn ear <br /> Z 1 Irlvlv <br /> t .Ink nat Shipments Import to U.S. ❑Expod filar US. Portofertoialt <br /> ;Tranaportor signatum(for am only): Date leaving U.S.; <br /> 17.Trane"tAddl gmmtel Recelptof Materials <br /> Transporter PdName Sign aWre Month Days.-y y„ <br /> mxag <br /> z ralMp 2 Pd teal Od Name malar Month Day Year <br /> 6 <br /> M <br /> f— <br /> ,} 16.Discrepancy <br /> 11ta.Mswpantylndim.Ion Space ❑ went �]Ty,pe ❑Residue ❑PaNaI RIJefWn ❑FulN dlon <br /> M ofiest Ref came Number <br /> 1ab,Alternate Fadely(cr Generator) US.EPA IO Number <br /> J <br /> U <br /> Fadlys Phare: <br /> w 180-Slgnalwa pfNlamate Facifity or eneraap Month Day Year <br /> d <br /> 2 <br /> H1S.HatardbA Waste Report Management Method Codes g.e.,codes for hazardous waste treatment,Disposal,and recycling systema) <br /> L ,. H I -I J 2 S. 4. <br /> OI 20.Designated Facility tamer or Operator.Certification of receipt of hemmoua materials covered by the manVesuzupt as noted in Item 1 ' <br /> yll Pdnled/typed Hama SignaWra / monthD6� 10-7 year <br /> o <br /> EPA I=8700-22(Rev.3-a5) Previauseditions amobsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED; <br /> No 'd Wd so :zo gal 010Z-bZ-9[lU <br />